White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DISORDERS OF THE BILIARY TRACT W MCC

Facility

$31,629.30

Service Code	MSDRG 444
Min. Negotiated Rate	$13,853.74
Max. Negotiated Rate	$31,629.30
Rate for Payer: BCBS of TX Blue Advantage	$13,853.74
Rate for Payer: BCBS of TX Blue Essentials	$16,622.88
Rate for Payer: BCBS of TX PPO	$18,470.58

DISORDERS OF THE BILIARY TRACT W/O CC/MCC

Facility

$15,422.30

Service Code	MSDRG 446
Min. Negotiated Rate	$6,837.00
Max. Negotiated Rate	$15,422.30
Rate for Payer: BCBS of TX Blue Advantage	$6,837.00
Rate for Payer: BCBS of TX Blue Essentials	$8,203.60
Rate for Payer: BCBS of TX PPO	$9,115.47

DISP INSTR KIT FOR SM JNT S-TAK

Facility

$1,098.68

Hospital Charge Code	992608
Hospital Revenue Code	272
Min. Negotiated Rate	$98.88
Max. Negotiated Rate	$791.05
Rate for Payer: Amerigroup CHIP/Medicaid	$98.88
Rate for Payer: BCBS of TX Blue Advantage	$329.60
Rate for Payer: BCBS of TX Blue Essentials	$395.52
Rate for Payer: BCBS of TX PPO	$439.47
Rate for Payer: Cash Price	$747.10
Rate for Payer: Cigna Medicaid	$791.05
Rate for Payer: Molina CHIP/Medicaid	$791.05
Rate for Payer: Multiplan Auto	$714.14
Rate for Payer: Multiplan Commercial	$714.14
Rate for Payer: Multiplan Workers Comp	$714.14
Rate for Payer: Parkland Medicaid	$791.05
Rate for Payer: Scott and White EPO/PPO	$549.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$791.05
Rate for Payer: Superior Health Plan EPO	$149.42

DISP INSTR KIT FOR SM JNT S-TAK

Facility

$1,098.68

Hospital Charge Code	992608
Hospital Revenue Code	272
Rate for Payer: Cash Price	$747.10

DISP INSTR, KIT FOR TENO SCREW

Facility

$1,475.50

Service Code	HCPCS C1713
Hospital Charge Code	992603
Hospital Revenue Code	278
Min. Negotiated Rate	$368.88
Max. Negotiated Rate	$737.75
Rate for Payer: Cash Price	$1,003.34
Rate for Payer: Cigna Commercial	$368.88
Rate for Payer: Multiplan Auto	$737.75
Rate for Payer: Multiplan Commercial	$737.75
Rate for Payer: Multiplan Workers Comp	$737.75
Rate for Payer: Scott and White EPO/PPO	$737.75

DISP INSTR, KIT FOR TENO SCREW

Facility

$1,475.50

Service Code	HCPCS C1713
Hospital Charge Code	992603
Hospital Revenue Code	278
Min. Negotiated Rate	$132.79
Max. Negotiated Rate	$1,062.36
Rate for Payer: Amerigroup CHIP/Medicaid	$132.79
Rate for Payer: BCBS of TX Blue Advantage	$442.65
Rate for Payer: BCBS of TX Blue Essentials	$531.18
Rate for Payer: BCBS of TX PPO	$590.20
Rate for Payer: Cash Price	$1,003.34
Rate for Payer: Cigna Medicaid	$1,062.36
Rate for Payer: Molina CHIP/Medicaid	$1,062.36
Rate for Payer: Multiplan Auto	$737.75
Rate for Payer: Multiplan Commercial	$737.75
Rate for Payer: Multiplan Workers Comp	$737.75
Rate for Payer: Parkland Medicaid	$1,062.36
Rate for Payer: Scott and White EPO/PPO	$737.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,062.36
Rate for Payer: Superior Health Plan EPO	$200.67

DISP INSTRS KIT FOR MINI S-TAK

Facility

$1,325.68

Hospital Charge Code	992611
Hospital Revenue Code	272
Min. Negotiated Rate	$119.31
Max. Negotiated Rate	$954.49
Rate for Payer: Amerigroup CHIP/Medicaid	$119.31
Rate for Payer: BCBS of TX Blue Advantage	$397.70
Rate for Payer: BCBS of TX Blue Essentials	$477.24
Rate for Payer: BCBS of TX PPO	$530.27
Rate for Payer: Cash Price	$901.46
Rate for Payer: Cigna Medicaid	$954.49
Rate for Payer: Molina CHIP/Medicaid	$954.49
Rate for Payer: Multiplan Auto	$861.69
Rate for Payer: Multiplan Commercial	$861.69
Rate for Payer: Multiplan Workers Comp	$861.69
Rate for Payer: Parkland Medicaid	$954.49
Rate for Payer: Scott and White EPO/PPO	$662.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$954.49
Rate for Payer: Superior Health Plan EPO	$180.29

DISP INSTRS KIT FOR MINI S-TAK

Facility

$1,325.68

Hospital Charge Code	992611
Hospital Revenue Code	272
Rate for Payer: Cash Price	$901.46

Disposable Exhalation Port

Facility

$154.36

Hospital Charge Code	993633
Hospital Revenue Code	270
Rate for Payer: Cash Price	$104.96

Disposable Exhalation Port

Facility

$154.36

Hospital Charge Code	993633
Hospital Revenue Code	270
Min. Negotiated Rate	$13.89
Max. Negotiated Rate	$111.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.89
Rate for Payer: BCBS of TX Blue Advantage	$46.31
Rate for Payer: BCBS of TX Blue Essentials	$55.57
Rate for Payer: BCBS of TX PPO	$61.74
Rate for Payer: Cash Price	$104.96
Rate for Payer: Cigna Medicaid	$111.14
Rate for Payer: Molina CHIP/Medicaid	$111.14
Rate for Payer: Multiplan Auto	$100.33
Rate for Payer: Multiplan Commercial	$100.33
Rate for Payer: Multiplan Workers Comp	$100.33
Rate for Payer: Parkland Medicaid	$111.14
Rate for Payer: Scott and White EPO/PPO	$77.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.14
Rate for Payer: Superior Health Plan EPO	$20.99

DISPOSABLE FLUTED HEADLESS PINS

Facility

$2,047.54

Service Code	HCPCS C1713
Hospital Charge Code	993505
Hospital Revenue Code	278
Min. Negotiated Rate	$184.28
Max. Negotiated Rate	$1,474.23
Rate for Payer: Amerigroup CHIP/Medicaid	$184.28
Rate for Payer: BCBS of TX Blue Advantage	$614.26
Rate for Payer: BCBS of TX Blue Essentials	$737.11
Rate for Payer: BCBS of TX PPO	$819.02
Rate for Payer: Cash Price	$1,392.33
Rate for Payer: Cigna Medicaid	$1,474.23
Rate for Payer: Molina CHIP/Medicaid	$1,474.23
Rate for Payer: Multiplan Auto	$1,023.77
Rate for Payer: Multiplan Commercial	$1,023.77
Rate for Payer: Multiplan Workers Comp	$1,023.77
Rate for Payer: Parkland Medicaid	$1,474.23
Rate for Payer: Scott and White EPO/PPO	$1,023.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,474.23
Rate for Payer: Superior Health Plan EPO	$278.47

DISPOSABLE FLUTED HEADLESS PINS

Facility

$2,047.54

Service Code	HCPCS C1713
Hospital Charge Code	993505
Hospital Revenue Code	278
Min. Negotiated Rate	$511.88
Max. Negotiated Rate	$1,023.77
Rate for Payer: Cash Price	$1,392.33
Rate for Payer: Cigna Commercial	$511.88
Rate for Payer: Multiplan Auto	$1,023.77
Rate for Payer: Multiplan Commercial	$1,023.77
Rate for Payer: Multiplan Workers Comp	$1,023.77
Rate for Payer: Scott and White EPO/PPO	$1,023.77

Disposable Infu-Surg Pressure Infusion Bag with Hook, 500 mL

Facility

$317.98

Hospital Charge Code	992912
Hospital Revenue Code	270
Rate for Payer: Cash Price	$216.23

Disposable Infu-Surg Pressure Infusion Bag with Hook, 500 mL

Facility

$317.98

Hospital Charge Code	992912
Hospital Revenue Code	270
Min. Negotiated Rate	$28.62
Max. Negotiated Rate	$228.95
Rate for Payer: Amerigroup CHIP/Medicaid	$28.62
Rate for Payer: BCBS of TX Blue Advantage	$95.39
Rate for Payer: BCBS of TX Blue Essentials	$114.47
Rate for Payer: BCBS of TX PPO	$127.19
Rate for Payer: Cash Price	$216.23
Rate for Payer: Cigna Medicaid	$228.95
Rate for Payer: Molina CHIP/Medicaid	$228.95
Rate for Payer: Multiplan Auto	$206.69
Rate for Payer: Multiplan Commercial	$206.69
Rate for Payer: Multiplan Workers Comp	$206.69
Rate for Payer: Parkland Medicaid	$228.95
Rate for Payer: Scott and White EPO/PPO	$158.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$228.95
Rate for Payer: Superior Health Plan EPO	$43.25

Disposable light handle cover, blue sterile

Facility

$6.27

Hospital Charge Code	992788
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.26

Disposable light handle cover, blue sterile

Facility

$6.27

Hospital Charge Code	992788
Hospital Revenue Code	272
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$4.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.56
Rate for Payer: BCBS of TX Blue Advantage	$1.88
Rate for Payer: BCBS of TX Blue Essentials	$2.26
Rate for Payer: BCBS of TX PPO	$2.51
Rate for Payer: Cash Price	$4.26
Rate for Payer: Cigna Medicaid	$4.51
Rate for Payer: Molina CHIP/Medicaid	$4.51
Rate for Payer: Multiplan Auto	$4.08
Rate for Payer: Multiplan Commercial	$4.08
Rate for Payer: Multiplan Workers Comp	$4.08
Rate for Payer: Parkland Medicaid	$4.51
Rate for Payer: Scott and White EPO/PPO	$3.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.51
Rate for Payer: Superior Health Plan EPO	$0.85

DISPOSABLE MIXING BOWLS W/S PATULA

Facility

$58.31

Hospital Charge Code	992723
Hospital Revenue Code	272
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$41.98
Rate for Payer: Amerigroup CHIP/Medicaid	$5.25
Rate for Payer: BCBS of TX Blue Advantage	$17.49
Rate for Payer: BCBS of TX Blue Essentials	$20.99
Rate for Payer: BCBS of TX PPO	$23.32
Rate for Payer: Cash Price	$39.65
Rate for Payer: Cigna Medicaid	$41.98
Rate for Payer: Molina CHIP/Medicaid	$41.98
Rate for Payer: Multiplan Auto	$37.90
Rate for Payer: Multiplan Commercial	$37.90
Rate for Payer: Multiplan Workers Comp	$37.90
Rate for Payer: Parkland Medicaid	$41.98
Rate for Payer: Scott and White EPO/PPO	$29.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.98
Rate for Payer: Superior Health Plan EPO	$7.93

DISPOSABLE MIXING BOWLS W/S PATULA

Facility

$58.31

Hospital Charge Code	992723
Hospital Revenue Code	272
Rate for Payer: Cash Price	$39.65

disposable or towel

Facility

$5.36

Hospital Charge Code	993755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.64

disposable or towel

Facility

$5.36

Hospital Charge Code	993755
Hospital Revenue Code	270
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$3.86
Rate for Payer: Amerigroup CHIP/Medicaid	$0.48
Rate for Payer: BCBS of TX Blue Advantage	$1.61
Rate for Payer: BCBS of TX Blue Essentials	$1.93
Rate for Payer: BCBS of TX PPO	$2.14
Rate for Payer: Cash Price	$3.64
Rate for Payer: Cigna Medicaid	$3.86
Rate for Payer: Molina CHIP/Medicaid	$3.86
Rate for Payer: Multiplan Auto	$3.48
Rate for Payer: Multiplan Commercial	$3.48
Rate for Payer: Multiplan Workers Comp	$3.48
Rate for Payer: Parkland Medicaid	$3.86
Rate for Payer: Scott and White EPO/PPO	$2.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.86
Rate for Payer: Superior Health Plan EPO	$0.73

DISPOSABLES KIT FOR DX KNOTLESS FIBERTAX

Facility

$2,083.86

Hospital Charge Code	992599
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,417.02

DISPOSABLES KIT FOR DX KNOTLESS FIBERTAX

Facility

$2,083.86

Hospital Charge Code	992599
Hospital Revenue Code	272
Min. Negotiated Rate	$187.55
Max. Negotiated Rate	$1,500.38
Rate for Payer: Amerigroup CHIP/Medicaid	$187.55
Rate for Payer: BCBS of TX Blue Advantage	$625.16
Rate for Payer: BCBS of TX Blue Essentials	$750.19
Rate for Payer: BCBS of TX PPO	$833.54
Rate for Payer: Cash Price	$1,417.02
Rate for Payer: Cigna Medicaid	$1,500.38
Rate for Payer: Molina CHIP/Medicaid	$1,500.38
Rate for Payer: Multiplan Auto	$1,354.51
Rate for Payer: Multiplan Commercial	$1,354.51
Rate for Payer: Multiplan Workers Comp	$1,354.51
Rate for Payer: Parkland Medicaid	$1,500.38
Rate for Payer: Scott and White EPO/PPO	$1,041.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,500.38
Rate for Payer: Superior Health Plan EPO	$283.40

Distilled Water, Laboratory Reagent Grade, 5-gal

Facility

$539.03

Hospital Charge Code	993339
Hospital Revenue Code	270
Min. Negotiated Rate	$48.51
Max. Negotiated Rate	$388.10
Rate for Payer: Amerigroup CHIP/Medicaid	$48.51
Rate for Payer: BCBS of TX Blue Advantage	$161.71
Rate for Payer: BCBS of TX Blue Essentials	$194.05
Rate for Payer: BCBS of TX PPO	$215.61
Rate for Payer: Cash Price	$366.54
Rate for Payer: Cigna Medicaid	$388.10
Rate for Payer: Molina CHIP/Medicaid	$388.10
Rate for Payer: Multiplan Auto	$350.37
Rate for Payer: Multiplan Commercial	$350.37
Rate for Payer: Multiplan Workers Comp	$350.37
Rate for Payer: Parkland Medicaid	$388.10
Rate for Payer: Scott and White EPO/PPO	$269.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$388.10
Rate for Payer: Superior Health Plan EPO	$73.31

Distilled Water, Laboratory Reagent Grade, 5-gal

Facility

$539.03

Hospital Charge Code	993339
Hospital Revenue Code	270
Rate for Payer: Cash Price	$366.54

DISTRACTOR LINEAR TELESCOPIC

Facility

$2,275.31

Hospital Charge Code	138444
Hospital Revenue Code	272
Min. Negotiated Rate	$204.78
Max. Negotiated Rate	$1,638.22
Rate for Payer: Amerigroup CHIP/Medicaid	$204.78
Rate for Payer: BCBS of TX Blue Advantage	$682.59
Rate for Payer: BCBS of TX Blue Essentials	$819.11
Rate for Payer: BCBS of TX PPO	$910.12
Rate for Payer: Cash Price	$1,547.21
Rate for Payer: Cigna Medicaid	$1,638.22
Rate for Payer: Molina CHIP/Medicaid	$1,638.22
Rate for Payer: Multiplan Auto	$1,478.95
Rate for Payer: Multiplan Commercial	$1,478.95
Rate for Payer: Multiplan Workers Comp	$1,478.95
Rate for Payer: Parkland Medicaid	$1,638.22
Rate for Payer: Scott and White EPO/PPO	$1,137.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,638.22
Rate for Payer: Superior Health Plan EPO	$309.44

Know your out-of-pocket cost for care.

All Charges